good evening and welcome to doctors on call i'm dr ray christensen faculty member from the department of family medicine and biobehavioral health at the university of minnesota medical school duluth campus i'm also a family physician at the gateway family health clinic in moose lake i'm your host for our program tonight on infectious disease and immunizations the success of this program is very dependent on you the viewer so please call in your questions tonight or email to ask at wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening are dr harmony tyner an infectious disease specialist with st luke's infectious disease associates and dr addy vittorio a family physician with saint luke's our medical students answering the phones tonight are barrett bukowick from aurora of minnesota andy cable from danube minnesota and emily clark from ivanhoe minnesota and now on to tonight's program on infectious disease and immunizations welcome both of you thank you addie great to see you again can you tell us a little bit about your practice and what you do i'm a family physician i work at two different clinics among st luke so the mount royal clinic um near the university and then also the leicester river clinic out furthest east off of 61. and i see a variety of patients day to day all the way from birth up to sort of elderly age we treat both sort of acute things like coughs colds you know other things that may come up as well as make sure people are healthy by giving them immunizations and doing our routine well well child and well adult visits great dr tyner tell us a little bit about your practice life i see patients inpatient and outpatient every day in patients that i see people in the hospital are the ones who have kind of complicated infections so prosthetic joint infections or bloodstream infections or mysterious infections infectious disease people get to kind of answer the mysteries or kind of dig into difficult things and in my clinic i follow patients with long-term infections such as hiv and hepatitis c and also see people when they come back from traveling and might have unusual things or might be preparing to travel thank you i think a good place to start is probably with flu the good old flu it's that time of year and the flu shots are being talked about eddie are you seeing influenza yet in your office we are actually not seeing influenza being diagnosed we do test for influenza frequently when we test for covid or other childhood infections but we really haven't seen a spike in cases as of yet it's still fairly early i think in this area we've seen the flu pop up you know kind of around the christmas time but also peaking in february and march in our spring months we are vaccinating people right now in our clinics for flu and there are a variety of vaccines available for different age groups um but it's a good thing to start getting vaccinated for the flu now dr tyner lost my train of thought on this one i think i know you're going with that yeah um with the influenza and with the virus out there uh what are you are as for st luke's where i was looking for was with the big system are you seeing any flu in the area or because we've got you isolated in your clinics so from a bigger standpoint flu not that we've seen a whole lot of we are testing for it regularly as well i'm not aware of a case yet in our county i haven't looked recently but i haven't heard of a new case in our county but we are also offering the flu vaccine and as like dr vittorio was saying there's a lot of different flu vaccines out there there are some common misconceptions about who should and shouldn't get the vaccine people who are concerned they might have an egg allergy the good news is that even if you have a history of an egg allergy a real egg allergy that prevents you from eating eggs it's still safe to get most flu shots and there's actually ones that are made without using eggs and there's a variety of other concerns too there's very few reasons not to get a flu shot they're safe and they're effective at preventing against uh infection that causes death well it's interesting that you bring up the egg allergy because there are a lot of people who are just no yeah and and that's not only because not only for the flu but for other vaccines also that's true you see quite a bit of pushback you know and i think that's one of the roles as a primary care doctor is it's my role in kind of being the first line to talk about the risks or the benefits to getting the vaccine and to sort of be able to give not political advice but more sort of sound medical advice of what we know about vaccines and what we know about how they can prevent disease if you look back in medical history there's some of the most sort of the greatest things that have happened in medicine so far in this century and the century prior so couldn't agree more i don't really want to go down the coveted line too far we've done that a lot this last month already but there is the question how far we talked earlier we can give a lot of shots at once or they need to be separated the big one is coming up right now because the covet booster all of a sudden is coming out the same time we're trying to give the influenza shot so what's one to do harmony i'll put that in your lap sure it is safe to get the coveted booster or any kovid shot at the same time as an influenza shot you can actually get many shots all in the same day but if they're not given on the same day you should wait two weeks to get your shot so if you get the coveted booster but didn't get your flu shot wait at least two weeks before getting your flu shot but it's also safe to get this on the same day there's a question we've got a lot of questions coming in and we'll probably we'll do our best last year we had a pretty flat flu season and at this time this year we really don't know so far i haven't seen much uh it seems like there's fewer flu cases this year and than in last year is this because we've been wearing masks should we keep wearing masks during future flu seasons i think that's a good question but it's also something we did see last year we saw a lot less flu last year and some of the speculation we haven't necessarily been able to test this is that we were wearing masks we were staying home when we were sick we weren't going out and exposing other people potentially to our illness and in other countries such as asian countries when you get sick you wear a mask or you don't go out you don't go to work in america that didn't sort of historically happen until more recently with the kovid 19 pandemic and i think it's great advice that when you're home or when you're sick you stay home you don't go to work when you're obviously sick and that we wear a mask when we're put potentially putting others at risk i think the second half of that question was about who should be wearing a mask right now and the cdc actually recommends that everyone be wearing a mask right now especially if you're in a public place indoors within proximity to other people and we know in minnesota that that's all winter long true and these infections are aerosol spread pretty much especially covid yes so yes do you increase an increase in flu cases this year anticipate an increase yeah i think that really depends on how people behave and sort of what we actually see with the strains that are out there this year and we we know very little right now this year because we haven't actually seen this worldwide or locally yet why do some people have such serious side effects with immunizations and others don't addie do you want to tackle that first from a primary care standpoint well i think it you know immunizations are designed to stimulate an immune response and that is the purpose of an immunization is to stimulate our bodies to produce antibodies so that if we're future exposed to something we can mount an immune response that's more robust than having not been exposed to it before and so there are genetically likely people who respond sort of immunologically more robustly to vaccines to allergens to diseases more so than others so some of this may be genetic it may also be based on their previous exposures to things that are similar or that have reacted similarly in their systems are there any vaccines other than tetanus that should be updated every few years and have a go at it either one of you it depends on the person actually tetanus is a great example some people who don't have a spleen should get more regular boosters of different vaccinations for example men in the meningococcal vaccine they should have more routinely there are different vaccines that are due at different ages as you go along so when you hit a certain age you should get the shingles shot and when you hit a certain age you should get a pneumonia shot so there are vaccines that kind of come up so once you hit 18 it's not like you're done getting shots um or annually like the flu shot so there are some that do recur but it depends on the person there's we've mentioned this before too there's actually over 80 vaccines that have been approved by the fda and we don't recommend all of them for everybody but everybody's different and everybody has a different immune system and different risk factors so and many of those vaccines can be used in people who have had had allergies to other vaccines in the past that's correct there are some very specific exceptions so if you've had a severe anaphylactic reaction to a specific component of vaccines we would look at the particular vaccine to see if you're at risk for that as well but that's extraordinarily rare and i think we kind of miss some people who may be at risk and need more vaccines but for an example anyone with a lung disease such as asthma or even a heavy smoker or someone with smoking-related lung disease heart disease we recommend throughout adulthood actually vaccinating for things like pneumonia routinely every five years the question for you harmony this person's had a splenectomy we'll not have we already started on this so maybe we want to just bring this out a little more well not having a spleen increase my risk of different infections yes specifically yes so we know that the spleen is particularly effective at clearing your blood from bacteria that have a gooey capsule around them and there are vaccines designed to protect you against those the vaccines include hemophilus influenza but the meningococcal vaccines and the pneumococcal vaccines and we do recommend having those vaccinations done so if you don't have a spleen you are at increased risk and we oftentimes will actually recommend that you carry an antibiotic with you as well if you don't have a spleen so yes you should see someone for vaccinations for that i heard shingrix come up a little bit ago too addie talk talk to us a little bit about shingrix and why a person should get it yeah and when shinriks is sort of our second generation shingle shot one came out several years ago which many people may have gotten that was considered what we call a live vaccine the new vaccine out for shingles that is recommended is called shingrix and it's not a live vaccine so it can be given to immunosuppressed persons and persons who are living with immunosuppressed persons shingrix protects against the childhood disease varicella or chickenpox but as adults that actually lives in sort of a component of our back in the nerve cells and so if you get sick physically even mentally stressed shingles can actually come out in the form of an itchy painful awful rash that occurs on one side of the body in particular and so there are recommendations for persons who've had chickenpox and persons who've not had chickenpox to be updated for the shingles vaccine when they reach age 50. and that's a two-part series so it's given initially and then six months later a booster dose is given and what we've seen with the new shingle shot is that it's very effective against shingles versus our older shots which were somewhat more marginally effective against shingles yeah i agree it's been a good immunization i hardly get sick why should i get a flu shot i think part of that is if you hardly get sick think about the others around you and that if even if you're a person who minimally gets symptoms just as we've seen with covet you can pass it around to people who are near you who may be more at risk not everyone's going to get influenza every year and having the flu shot will reduce the severity of is likely to reduce the severity of your infection it's a moment of of a shot but getting an actual influenza infection can knock you down for over a week well influenza is not without risk either is definitely not i forget the numbers but the there's a death rate that's fairly significant it's not as bad as covid but it's there definitely so there's there's good reasons too and i think both harmony and i have probably seen people in the hospital who you wouldn't necessarily feel are at risk for influenza who've done you know surprisingly very poorly with influenza yeah we as well certainly see in non-covered years i see people die from influenza every year they're i hate to say blanket statements but i cannot think of a single one who was vaccinated who passed away from influenza that i've taken care of and that seems to be the thread that's running with covet also immunization is quite protective what practices implemented during the covet pandemic will persist after the pandemic is over it's an interesting question and i've i've mulled on it a little bit as i think about it so i'm wondering am i going to be wearing a mask and goggles in the office because i think about the size of the office air exchange and all of the other factors are there things that are going to persist are we going to see better air exchange systems i don't know i don't know i don't know that we've you know proven the air exchanges is sort of the go-to for this i think we've proven that if you stay home when you're sick and you protect others by having some sort of barrier those things may stick um i would hope that employer sort of practices would stick a little bit regarding sick days and working from home but again not sure in america if that will stick either i really hope that through all this we learn how to be kinder to each other i hope that sticks yes and then the importance of public health versus my personal beliefs that's a that's a tough one i'm getting knee surgery soon how concerned should i be about getting exposed to bacteria and viruses at the hospital harmony i'll turn that one to you um so one of the interesting things that's easy to forget is that bacteria and viruses are everywhere the world is covered in bacteria and anyone who has me over is a dinner guest knows that i love to say the world is covered in poop because it really is it's just everywhere these germs are everywhere in your environment in your home on your skin yes they're in the hospital as well how much are you at risk in the hospital versus outside of the hospital there can be more resistant germs in the hospital the things to do while you're in the hospital or the same things you would do at home wash your hands bathe and follow your doctor's recommendations they may ask you to do a body wash ahead of your surgery and that's a good idea as well how concerned should you be about one in three one to three percent of all uh joints become infected during surgery so one to three percent is how concerned you should be thank you addie what immunizations are considered essential before going to college well um as a family doctor i would say your childhood vaccines would be important however the most important thing probably is to think about what you'll be doing in college and so the majority of people either going off to the military or going off to college are going to live with one two three or more people and so when you live in course close quarters we do recommend that you update your meningitis shots and meningitis is given at the age of 11 to 12 and then a booster dose is given between age 16 to 18 and and over the past couple of years we've actually developed a second meningitis shot so there's two different types and the meningococcal b is sort of the newer type but we recommend two doses between 16 and 18 for that those are probably the most important outside of getting a tetanus shot every 10 years and then making sure your other immunizations from childhood are updated obviously we're not at risk for some of the severe infections that infants see but we're certainly always at risk for polio when we live in close quarters with people and some of the other things we vaccinate routinely before going why does our tetanus shot have to be a dt or whatever it is now harmony uh so tetanus can sometimes be paired with uh let's see it's pertussis you're gonna ask me about the theory and pertussis so you usually don't just get one you get all three now it's usually tetanus and diphtheria together why does tetanus wane why do some why does the immunity against some vaccines wane i don't know the answer to that question it's a really good immunologic question our immunization weans wanes and it's it's good to be boosted it happens and i think if you're exposed to pertussis and who's at risk for pertussis what we see our outbreaks in this area in school-age and middle school-aged kids tend to pass around pertussis pertussis is in older people you know older being over the the age of an infant results in a severe uncontrollable cough often for weeks and weeks at a time vomiting after coughing is very common and so persons exposed to children in those age groups are at risk and so i recommend most parents or grandparents try to get the tdap which has the pertussis in it this is an interesting question and either one of you can go after it i was thinking about putting a dryer sheet in my mask to provide a better smell is it harmful for me to breathe that in i think it's probably less of an infectious disease question and more of a toxic exposure question yeah i think that they're pushing it your way kind of yeah so i agree anything we smell involves a volatile compound that sort of goes into our nose and and a lot of times if it's a commercial product it can be a chemical or some sort of compound that may not be great for us to be in close quarters with i agree with that why do some people have i think we've already talked about this such heavy side effects with some of the covet vaccines and i guess we kind of discussed that we all react a little bit differently to them so there's a question in here about the different types of covet vaccines do you want to briefly just discuss those maybe harmony that falls in your purview sure currently the in this country there's two different kinds of coveted vaccines the one that we kind of hear the most about are the mrna vaccines which are basically a tiny bit of rna which is a messenger piece of genetic material that tells your body to make a protein that that protein then goes out and is recognized by your body this protein is presented via antigen presenting cells to your b cells which then recognize it and then make antibodies against it that genetic material is kind of like cotton candy it evaporates almost immediately after it's recognized and those proteins are treated like every other protein in your body and they rapidly disappear out of your blood as well they don't stick around and by presenting this antigen to your body you make antibodies that's the mrna vaccine the johnson johnson vaccine is a more traditional vaccine and instead of using a genetic piece of material to teach your body to make that protein it just gives you the protein almost identical mechanism of producing antibodies just that one step is different they're very similar in actual practice back to shingles we've got a couple of shingles questions i've the first one is i've had shingles and have not had the vaccine will getting the vaccine be helpful for me after i've had shingles that's one and i've had shingles twice do i still need to get the shingles vaccine so kind of pull those kind of two parts are kind of putting that together is once you get shingles you're actually likely to get more outbreaks as you go along so you're certainly more at risk than sort of your friend who's maybe never had shingles before and there is a point where yes when you get shingles and it kind of presents itself to the body you will get some antibodies but they don't last forever and so and we don't really know sort of the amount of time but we still do recommend even after having multiple episodes of shingles that you be vaccinated and we definitely see less outbreaks after vaccination this person had a covet booster 45 days after breakthrough covet infection uh i heard you are supposed to wait 90 days are there any harmful side effects with getting it sooner and we kind of chatted about this before we did there's not any risk to getting it sooner the original rationale behind 90 days was because there was a relative shortage of vaccine we don't have that anymore we presumed that people who had infection probably had at least 90 days of immunity before their immunity would wane to the point they would need vaccine there is evidence now there's a new england journal article that came out several months ago that suggested if you did wait a month two months up to three months the amount of immune boosting you would get might be larger but it's not going to cause any harm to get it sooner than that there's a question asking us to elaborate more on the cdc warning on myocarditis and adolescents and young adults especially after the second covid vaccine i'm not aware of this one so i don't know anything about this we were talking about this before we came on actually so so myocarditis does exist as we've talked about and it is a vaccine side effect the risk is extremely low but it is something that an otherwise healthy person who gets a vaccine can experience we also know that myocarditis is a complication of covet infection itself about 15 fold higher if you have a cova infection to get myocarditis or 15 times more other viruses can also cause myocarditis but we have seen as a side effect of vaccination in otherwise healthy people a slight increase in myocarditis it's not zero we talked earlier harmony you and i a little bit about risk factors for vaccines do you want to elaborate we talked a little bit about travel and things that you look at and maybe people should think about yeah so like i mentioned there's over 80 different kinds of vaccines out there that have been approved by the fda we don't recommend them for everybody there's yellow fever and cholera and dengue for people who are traveling there are peop vaccines for people who are going to be living in congregate settings like going to college and who don't have spleens or who have hiv whoever has an immune risk or has a chronic disease like chronic kidney disease or chronic lung disease could consider having a vaccine visit to see if they should be vaccinated against any additional infections this past summer tick diseases or not addie i've actually seen quite a few tick-borne diseases even late in the fall so within the past couple of weeks and strange presentations of tick-borne disease you know getting just one single rash or getting a whole body rash that looks nothing like a lime rash so if you have exposure to deer ticks or ticks in general or you have you know symptoms that may reflect tick-borne disease and you have the risk of you know being an outdoors person it's worth seeing your doctor and getting evaluated and potentially checked for those are you seeing an increase in the common illnesses this year versus last year now that people are mixing again i think so but i think the other thing is last year we didn't see people when they got common illnesses most people were kind of staying out of the hospital staying out of the clinics and this year we're seeing people access the health care system because they either feel more comfortable or we've initiated practices that make it easier to do so so i think we're just seeing more people in general we're basically out of time so i'm not going to push another question at you but thank you very much for a very interesting program there was a lot of information that we went over this evening i want to thank our panelists dr harmony tyner and dr addie vittorio vittorio and our medical student volunteers barrett bukowitz andy cable and emily clark please join dr mary owen next week for a program on stroke and other neurologic problems when her panelists will be dr vikram jadav and dr john wood thank you for watching good night [Music] 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